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Coordinating Mental Health Transfer of Care

Project Added:
31 March 2015
Last updated:
17 April 2015

Coordinating Mental Health Transfer of Care


Essential to seamless transfer of care is the engagement of and communication with relevant clinicians from the inpatient and community settings, as well as the consumer or carer during discharge planning. This project has highlighted the real issues underlying care coordination, which have persisted and become more complex as local services have evolved. An objective analysis of these issues has occurred with focused strategies and an implementation plan that places the patient at the centre of care.


To ensure that within six months, 90% of acute mental health inpatients at Murrumbidgee Local Health District (MLHD) who require transfer of care to Community Mental Health services, receive a discharge planning meeting attended by a community clinician and consumer.


  • Safe, effective and coordinated transfer of care for patients discharged from the Acute Mental Health Inpatient Unit to MLHD Community Mental Health services.
  • Improved consumer and carer engagement in the discharge planning process.
  • Increased consumer, carer and clinician satisfaction.
  • Transparency, clarification and standardisation of the process and expectations for coordinating transfer of care.
  • Clinical redesign that produces sustainable, patient-centred solutions to long-standing, complex systems issues around mental health care coordination.
  • Achievement of Tier 2 safety and quality targets, including 28-day re-admission rates and seven-day post-acute care follow up in the community.

Project status

Project start date: 3 September 2014

Project review date: June 2015

Project status: Implementation - the initiative is ready for implementation, is currently being implemented, piloted or tested.


Coordinating transfer of care from the Acute Mental Health Inpatient Unit to Community Mental Health teams has historically proved challenging. Inpatient and community teams operate on different schedules with different personnel and systems, with significant travel distances between mental health teams, consumers and acute mental health units. These factors have led to issues in coordinating transfer of care.


A three-month trial was implemented, which involved:

  • establishing a process to share contact details of current clinicians between inpatient and community settings each month
  • identifying key clinicians for consumers to contact, to facilitate ease of communication between inpatient and community teams
  • an updated daily handover sheet from the inpatient unit to Community Mental Health Teams, which reflects who the key inpatient and allocated community clinicians are for each consumer
  • the development of a flowchart which was disseminated to define communication channels and roles within the process.


Clinical Excellence Commission (CEC) Executive Clinical Leadership Program

Implementation sites

  • Mental Health Acute Inpatient Unit, Wagga Wagga Health Service.
  • Community Mental Health Teams in Deniliquin, Griffith, Temora, Tumut, Wagga Wagga and Young.


A review in June 2015 will:

  • review seven-day community follow up and 28-day re-admissions data
  • survey clinicians, consumers and carers for satisfaction with the process
  • repeat the file audit to determine whether the project aim is met.

This project was nominated for a MLHD Excellence Award.


Sonya Bull
Mental Health Drug and Alcohol Governance Manager
Mental Health Drug and Alcohol Directorate
Murrumbidgee Local Health District
Phone: 0429 365415

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